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APPENDIX A The Committee's Recommendations MONITORING THE EPIDEMIC'S COURSE The committee recommends that an appropriate federal agency mount a continuing program to monitor HIV testing at all labo- ratories doing such testing. The committee recommends that CDC and other agencies with HIV/AIDS data gathering and reporting functions review their data disclosure practices, searching for rules and setting policies that con- tinue to safeguard confidentiality but do so at the least practical cost in information. The committee recommends that efforts be made to reformulate the CDC family of seroprevalence surveys as probability samples. The committee recommends instituting a continuing anonymous probability survey of the HIV serostatus of women who are clients of clinics that provide abortion services. The committee recommencis that the newborn infant seroprevaTence survey be extended to include all children born in the United States. HUMAN SEXUAL BEHAVIOR AND AIDS The committee recommends that the Public Health Service support vigorous programs of basic social and behavioral research on human sexual behavior, particularly through such agencies as the National 405

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406 ~ APPENDIX A Institutes of Health; the Alcohol, Drug Abuse, and Mental Health Administration; and the Centers for Disease Control. The committee recommends that ciata be collected to estimate the prevalence of the sexual risk-taking behaviors associated with the acquisition and spread of HIV infection in various populations, in- cluding those at higher and lower risk. The committee recommends that funding be provided (and contin- ued over time) to support prospective longitudinal studies of sexual behavior, and that high priority be given to studies of the social and societal contexts of sexual behaviors. The committee recommends that the Public Health Service support research in those subsets of the population that are at increased risk of HIV infection. The committee recommends immediate steps to close the vast gaps in our knowledge of the relationship of sexual behavior and drug and alcohol use. The committee recommencis that resources be invested in method- ological research to develop better procedures to obtain information from hard-to-reach groups. The committee recommends that an indepenclent review of STD ciata collection systems be undertaken and sufficient resources provicled to undertake any improvements that may be required. The committee recommends that the Public Health Service immedi- ately begin a research program to determine the extent to which the use of condoms and spermicides reduces the risk of HIV transmission. This program should inclucle investigations of the current use of these products, how that use might be modified, and equally important how these products themselves may be modified to encourage uses compatible with human skills and dispositions. The committee recommencis a concerted effort to upgrade and stan- dardize (when possible and clesirable) the procedures used to gather behavioral data in clinical and biomedical research settings. The committee recommends that funcling agencies, both public and private, encourage the sharing of data relevant to HIV infection and AIDS that have been gathered by federal and extramural researchers,

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APPENDIX A ~ 407 within the limits set by scientific priority ant! confidentiality. To fa- cilitate such sharing, the committee recommends that a data archive be established to support secondary analyses of these data. The committee recommends that local public health authorities en- sure that treatment for all sexually transmitted diseases is readily available to all persons who may seek such treatment. The committee recommends that local public health authorities en- sure that condoms are readily available to all sexually active persons. AIDS AND IV DRUG USE The committee recommends that well-clesigned, staged trials of ster- ile needle programs, such as those requested in the 1986 Institute of Medicine/National Academy of Sciences report Confronting AIDS, be implemented.) The committee recommends that high priority be given to studies of the social and societal contexts of IV drug use and IV drug-use prevention efforts. The committee recommends that high priority be given to research on the natural history of IV drug use, with an emphasis on prospective longitudinal studies of the factors associated with initiation into and cessation of {V drug use. The committee recommends that high priority be given to studies of the sexual and procreative behavior of IV drug users, including methods to reduce sexual and perinatal (mother-infant) transmission of HIV. The committee recommends that the appropriate government au- thorities take immediate action to (1) provide drug treatment upon request for IV drug users throughout the country; (2) sustain and expand current programs that provide for "safer injection" to reach all current IV drug users in the nation on a continuing basis and with appropriate research evaluation; and (3) establish data collec- tion systems for monitoring present AIDS prevention efforts for {V drug users. fin the text of the report, this recommendation appears in Chapter 4.

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408 ~ APPENDIX A The committee recommends that high priority be given to research that will lead to improved drug-use treatment, including studies of relapse prevention and of treatment for cocaine dependence. Ap- plied research should include planned variation and evaluation of experimental programs. The committee recommends that high priority be given to studies of IV drug users who are not in contact with health care, drug-use treatment, or criminal justice systems. The committee recommends that high priority be given to method- ological studies to determine ways of improving the quality of self- reports of sexual and drug-use behavior. The committee recommends that high priority be given to research on the estimation of the current number of IV drug users in the United States and of seroprevalence rates among different groups of IV drug users. FACILITATING CHANGE IN HEALTH BEHAVIORS The committee recommends making information available in clear, explicit language in the idiom of the target audience. The committee recommends that AIDS prevention messages strike a balance in the level of threat that is conveyed. The committee recommends that television networks present more public service messages on those behaviors associated with HIV transmission and practical measures for interrupting the spread of infection. The committee recommends that television networks accept condom advertisements. The committee recommends that programs to initiate and sustain changes in risk-associated behavior take into account how the tar- geted population perceives and understands risk. . The committee recommends that innovative approaches to AIDS prevention programs be introduced in a planned manner that reflects well-established principles about the adoption and diffusion of new ideas.

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APPENDIX A | 409 The committee recommends that programs to facilitate behavioral change be approached as long-term efforts, with multiple and re- peated strategies to initiate and sustain behavioral change over time. The committee recommends that anonymous HIV antibody testing with appropriate pre- and posttest counseling be made available on a voluntary basis for anyone desiring it. The committee recommends that programs consider the psychologi- cal, social, biological, and environmental factors that may affect re- lapse; learned coping responses, including skills training anct relapse rehearsal, should be taught to increase perceptions of self-efficacy. The committee recommends that, to the extent possible, community- level interventions to prevent the spread of HIV infection address simultaneously information, motivational factors, skills, prevailing norms, and methods for diffusing innovation. The committee recommends that sex education be available to both mate and female students and that such education inclucle explicit information relevant to the prevention of HIV infection. The committee recommends that planned variations of key program elements be systematically and actively incorporated into the design of intervention programs at an early stage. The committee recommends that the Public Health Service and oth- ers conducting or supporting intervention programs ensure the im- plementation of planned variations in AIDS messages? programs, and . campaigns. EVALUATING THE EFFECTS OF AIDS INTERVENTIONS The committee recommends that the Office of the Assistant Secretary for Health take responsibility for an evaluation strategy that will provide timely information on the relative effectiveness of different AIDS intervention programs. The committee recommends the expanded use of randomized field experiments for evaluating new intervention programs on both indi- vidual and community levels.

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410 ~ APPENDIX A The committee recommends that evaluation support be provided to ensure collaboration between practitioners and evaluation re- searchers. The committee recommends to the research community that the results of well-conducted evaluations be published, regardless of the intervention's effectiveness. The committee recommends that all evaluations publish detailed descriptive information on the nature and methods of intervention programs, along with evaluation data to support claims of relative effectiveness. The committee recommends that only the best-designed and best- implemented intervention programs be selected to receive those spe- cial resources that will be needed to conduct scientific evaluations. The committee recommencis that CDC substantially increase efforts, with links to extramural scientific resources, to assist health depart- ments and others in mounting evaluations. BARRIERS TO RESEARCH The committee recommends that serious consideration be given to exempting research on HIV infection and AIDS from the require- ments of the Paperwork Reduction Act. The committee recommends that intervention programs at all levels increase the involvement of minority researchers and minority health care workers to assist in reaching and involving the black, Hispanic, and gay communities. The committee recommends that support of multidisciplinary cen- ters for research on AIDS prevention be viewed as a long-term com- mitment to allow sustained collaborative efforts, including valuable prospective studies. The committee recommends that the number of trained behavioral and social scientists employed in AIDS-related activities at federal agencies responsible for preventing the spread of HIV infection be substantially increasecl.

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APPENDIX A ~ 411 The committee recommends that the CDC AIDS program increase its staff of persons knowledgeable about survey sampling and sur- vey design, and that it exploit the methodological expertise of the National Center for Health Statistics. The committee recommends that, in addition to experienced survey scientists, CDC obtain technical assistance to evaluate intervention programs it is currently funding. The committee recommencis the use of PHS fellowship programs and Intergovernmental Personnel Appointments (IPAs) as an in- terim means for rapidly enlarging the cadre of senior behavioral and social scientists working on AIDS programs at CDC and other PHS agencies.